Get the free c-impact clinic referral form

Cimpact Clinic (a division of Chealth)6720 104 Street NW Edmonton, AB T6H 2L4 Ph: (780) 3065555 Fx: (780) 4312554 www.chealth.caCIMPACT CLINIC REFERRAL FORM PATIENT INFORMATION (attach patient label)

How to fill out c-impact clinic referral form

How to fill out c-impact clinic referral form

1. Obtain a copy of the C-Impact Clinic referral form.
2. Fill in the patient's personal information such as name, date of birth, and contact details.
3. Provide details of the referring physician or healthcare provider.
4. Include information about the reason for referral and any relevant medical history.
5. Ensure all sections of the form are completed accurately and legibly.
6. Submit the completed referral form to the C-Impact Clinic according to their preferred method of submission.

Who needs c-impact clinic referral form?

1. Patients who have been advised by their physician to seek specialized care at the C-Impact Clinic.
2. Healthcare providers looking to refer a patient to the C-Impact Clinic for further evaluation or treatment.

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What is c-impact clinic referral form?

c-impact clinic referral form is a document used to refer patients to a specific clinic for treatment or consultation.

Who is required to file c-impact clinic referral form?

Healthcare providers or professionals responsible for referring patients to clinics are required to file c-impact clinic referral form.

How to fill out c-impact clinic referral form?

To fill out c-impact clinic referral form, the healthcare provider must input patient information, reason for referral, clinic details, and any relevant medical history.

What is the purpose of c-impact clinic referral form?

The purpose of c-impact clinic referral form is to streamline the process of referring patients to specific clinics for specialized treatment or consultation.

What information must be reported on c-impact clinic referral form?

Information such as patient details, reason for referral, clinic information, medical history, and any relevant documents must be reported on c-impact clinic referral form.